HEART FAILURE
 clinical syndrome resulting from structural or
functional cardiac disorders that impair the
ability of the ventricles to fill or eject blood
 often referred to as congestive heart failure
(CHF), because many patients experience
pulmonary or peripheral congestion with
edema
 clinical syndrome characterized by signs and
symptoms of fluid overload or inadequate tissue
perfusion
 indicates myocardial disease in which impaired
contraction of the heart (systolic dysfunction) or
filling of the heart (diastolic dysfunction) may
cause pulmonary or systemic congestion
Two major types of HF
 Systolic heart failure
o alteration in ventricular contraction
characterized by a weakened heart
muscle
 Diastolic heart failure
o characterized by a stiff and
noncompliant heart muscle, making it
difficult for the ventricle to fill
Etiology
 coronary artery disease
 hypertension
 cardiomyopathy
 valvular disorder
 renal dysfunction with volume overload
 diabetes
Clinical Manifestations
A. Left-Sided Heart Failure
 Pulmonary congestion
 Dyspnea, cough, pulmonary crackles, and
low oxygen saturation levels
 S3, or “ventricular gallop,” may be detected
on auscultation - caused by abnormal
ventricular filling
 dyspnea on exertion
 orthopnea - may use pillows to prop
themselves up in bed, or they may sit in a
chair and even sleep sitting up
 paroxysmal nocturnal dyspnea - sudden
attacks of dyspnea at night
 cough initially dry and nonproductive -dry
hacking cough
 cough may become moist over time - Large
quantities of frothy sputum (pink or tan
(blood tinged))
 bibasilar crackles that do not clear with
coughing
 oliguria when awake
 frequent urination at night (nocturia) –
decrease workload of the heart during
sleeping
 Increase blood pressure
 dizziness, lightheadedness, confusion,
restlessness, and anxiety
 heart rate (tachycardia) and palpitations
 peripheral pulses become weak
 easily fatigued and has decreased activity
tolerance
B. Right-Sided Heart Failure
 congestion in the peripheral tissues and the
viscera predominates
 jugular venous distention (JVD)
 edema of the lower extremities (dependent
edema)
 hepatomegaly (enlargement of the liver)
 ascites (accumulation of fluid in the
peritoneal cavity)
 weight gain due to retention of fluid
 Anorexia (loss of appetite), nausea, or
abdominal pain
 generalized weakness
Assessment and Diagnostic Findings
 echocardiogram - to determine the EF, identify
anatomic features and confirm the diagnosis of
HF
 chest x-ray and a 12-lead electrocardiogram
(ECG)
 serum electrolytes, blood urea nitrogen (BUN),
creatinine, liver function tests, complete blood
count (CBC), BNP, and routine urinalysis
Medical Management
 Goals
o To relieve patient symptoms
o To improve functional status and quality
of life
o to extend survival
 Objectives of guideline-directed patient
management
o Improvement of cardiac function with
optimal pharmacologic management
o Reduction of symptoms and
improvement of functional status
o Stabilization of patient condition and
lowering of the risk of hospitalization
o Delay of the progression of HF and
extension of life expectancy
o Promotion of a lifestyle conducive to
cardiac health
Pharmacologic Therapy
 Angiotensin-Converting Enzyme Inhibitors
 o promote vasodilation and diuresis,
ultimately decreasing afterload and
preload
o decrease the secretion of
aldosterone, a hormone that causes
the kidneys to retain sodium and
water
o monitor for hypotension,
hyperkalemia (increased potassium in
the blood), and alterations in renal
function
o ACE inhibitors may be discontinued if
the potassium level remains greater
than 5.5 mEq/L or if the serum
creatinine rises
 Angiotensin Receptor Blockers
o similar hemodynamic effects and side
effects with ACE inhibitors
o block the vasoconstricting effects of
angiotensin II at the angiotensin II
receptors
o alternative to ACE inhibitors
 Beta-Blockers
o block the adverse effects of the
sympathetic nervous system
o relax blood vessels, lower blood
pressure, decrease afterload, and
decrease cardiac workload
 Diuretics
o to remove excess extracellular fluid
by increasing the rate of urine
produced
o Loop diuretics - inhibit sodium and
chloride reabsorption mainly in the
ascending loop of Henle
o Thiazide diuretics - inhibit sodium and
chloride reabsorption in the early
distal tubules
o Aldosterone antagonists - block the
effects of aldosterone in the distal
tubule and collecting duct (Aldactone)
 Digitalis
o an essential agent for the treatment
of HF
o increases the force of myocardial
contraction and slows conduction
through the atrioventricular node
o positive inotropic and negative
chronotropic effect
o Patients with renal dysfunction and
older patients should receive smaller
doses of digoxin, as it is excreted
through the kidneys
o key concern associated with digoxin
therapy is digitalis toxicity
o Watch out for anorexia, nausea,
visual disturbances, confusion, and
bradycardia
o serum potassium level is monitored
because the effect of digoxin is
enhanced in the presence of
hypokalemia and digoxin toxicity may
occur
o serum digoxin level is obtained if the
patient’s renal function changes or
there are symptoms of toxicity
 Intravenous Infusions
o IV inotropes (milrinone [Primacor],
dobutamine [Dobutrex])
o increase the force of myocardial
contraction
o used for patients who do not respond
to routine pharmacologic therapy and
are reserved for patients with severe
ventricular dysfunction
Nutritional Therapy
 low-sodium (no more than 2 g/day) diet
 avoiding excessive fluid intake
 consider good nutrition as well as the patient’s
likes, dislikes, and cultural food patterns
 Patient adherence is important because dietary
indiscretions may result in severe exacerbations
of HF requiring hospitalization
Supplemental Oxygen
Nursing Interventions
A. PROMOTING ACTIVITY TOLERANCE
 Avoid prolonged physical inactivity - pressure
ulcers (especially in edematous patients) and
venous thromboembolism
 Exercise training - daily walking regimen
 schedule should alternate activities with
periods of rest
 Small, frequent meals decrease the amount
of energy needed for digestion while
providing adequate nutrition
 nurse helps the patient identify peak and low
periods of energy, planning energy-
consuming activities for peak periods
 patient’s response to activities needs to be
monitored
 limit physical activities to only 3 to 5 minutes
at a time, one to four times per day
B. MANAGING FLUID VOLUME
 Oral diuretics should be given early in the Cardiac Arrest
morning
 limit physical activities to only 3 to 5 minutes  heart is unable to pump and circulate blood to
at a time, one to four times per day the body’s organs and tissues
 assisting the patient to adhere to a low-  caused by a dysrhythmia such as ventricular
sodium diet by reading food labels and fibrillation, progressive bradycardia, or asystole
avoiding high-sodium foods such as canned,  Cardiac arrest can also occur when electrical
processed, and convenience foods activity is present on the ECG but cardiac
 assist the patient to plan fluid intake contractions are ineffective, a condition called
throughout the day while respecting the pulseless electrical activity (PEA)
patient’s dietary preferences Clinical Manifestations
 amount of fluid needs to be monitored
closely  consciousness, pulse, and blood pressure are
 patient is positioned or taught how to assume lost immediately
a position that facilitates breathing - number  Breathing usually ceases, but ineffective
of pillows may be increased, the head of the respiratory gasping may occur
bed may be elevated, or the patient may sit in  pupils of the eyes begin dilating in less than a
a recliner minute, and seizures may occur
 assesses for skin breakdown and institutes  Pallor and cyanosis
preventive measures  irreversible brain damage, and of death
 Positioning to avoid pressure and frequent increases with every minute that passes
changes of position help prevent pressure Emergency Assessment and Management:
ulcers
C. CONTROLLING ANXIETY  Cardiopulmonary Resuscitation
 promote physical comfort and provide 
psychological support
 When patients with HF are delirious,
confused, or anxious, restraints should be
avoided. Restraints are likely to be resisted,
and resistance inevitably increases the
cardiac workload.
D. MONITORING AND MANAGING POTENTIAL
COMPLICATIONS
 pulmonary edema, kidney injury, and
lifethreatening dysrhythmias
 Excessive and repeated diuresis can lead to
hypokalemia
 Hyperkalemia may occur, especially with the
use of ACE inhibitors, ARBs, or spironolactone
 Prolonged diuretic therapy may produce
hyponatremia (deficiency of sodium in the
blood), which can result in disorientation,
weakness, muscle cramps, and anorexia
 Volume depletion from excessive fluid loss
may lead to dehydration and hypotension.
ACE inhibitors and beta-blockers may
contribute to the hypotension
 Other problems associated with diuretics
include increased serum creatinine (indicative
of renal dysfunction) and hyperuricemia
(excessive uric acid in the blood), which leads
to gout